Ohio



|[pic] |OHIO DEPARTMENT OF PUBLIC SAFETY | |

| |BUREAU OF MOTOR VEHICLES | |

| | | |

| |INDIVIDUAL’S REQUEST FOR NATIONAL DRIVER REGISTER (NDR) | |

| |FILE CHECK IN ACCORDANCE WITH THE | |

| |PRIVACY ACT OF 1974 (PUBLIC LAW 93-579) | |

|The National Driver Register (NDR) contains only a listing of names and related identification, provided by State driver licensing officials, of those drivers |

|whose driver licenses have been cancelled, denied, revoked, or suspended or who have been convicted of certain serious traffic violations such as Driving Under the|

|Influence of Alcohol. The NDR does not contain a list of any other drivers. If you have not had a driver license cancelled, denied, revoked, or suspended or have |

|not been convicted of serious traffic violations, you would not be listed in the NDR. Every individual is entitled, however, to request a check of the NDR records |

|to determine whether or not they appear on the NDR file. A reply is made to every valid NDR inquiry. The record content for those persons who are listed in the NDR|

|files is limited to identification of the state(s) which have taken action to cancel, deny, revoke, or suspend or have records of conviction of serious traffic |

|violations. Any specific information about the driver history, or a request, for the entire driver history, can be obtained only from the state(s) where the |

|detailed information is recorded. If the NDR has a record on you, the full record will be copied and sent to you including older records which may have contained a|

|reason for license cancellation, denial, revocation, or suspension. In addition, if such information has been disclosed by the NDR, the recipient of the |

|information will also be identified. The name and address of the State driver licensing official will be provided for each State listed as having reported |

|information on you to the NDR. |

|TYPE OR PRINT LEGIBLY AVOID DELAYS - INQUIRIES THAT CANNOT BE READ WILL NOT BE PROCESSED |

|FULL LEGAL NAME (FIRST, MIDDLE, AND LAST AS SHOWN ON YOUR DRIVER LICENSE) |

|      |

|OTHER NAMES USED (MAIDEN, PRIOR NAME, NICKNAME, PROFESSIONAL NAME, OTHER) |

|      |

|ADDRESS (NUMBER AND STREET WITH APARTMENT NUMBER IF ANY OR RURAL ROUTE / CARRIER AND BOX NUMBER- AS SHOWN ON YOUR DRIVER LICENSE) |

|      |

|CURRENT MAILING ADDRESS IF DIFFERENT (NUMBER, STREET, APARTMENT NUMBER OR RURAL ROUTE / CARRIER AND BOX NUMBER) |HOME TELEPHONE (VOLUNTARY) |

|      |(     )     -      |

|CITY |STATE |ZIP |WORK TELEPHONE (VOLUNTARY) |

|      |      |      |(     )     -      |

|DRIVER LICENSE NUMBER AND STATE |SOCIAL SECURITY NUMBER (VOLUNTARY) |

|      |      |

|DATE OF BIRTH |SEX |EYE COLOR |HEIGHT |WEIGHT |

|      |      |      |      |      |

|UNDER THE PRIVACY ACT OF 1974, I HAVE THE RIGHT TO REQUEST RECORD(S) PERTAINING TO ME FROM THE NDR AND TO CORRECT ANY ERROR IN SUCH RECORD(S).I HEREBY, WITH MY |

|SIGNATURE, AUTHORIZE A ONE - TIME FILE SEARCH OF THE NDR. |

|APPLICANT SIGNATURE |DATE |

|X |      |

|Notary: |

|Sworn to and subscribed in my presence this day of , 20 in County, |

|State of . |

|(Notary Seal) |

|Signature of Notary Public X My commission expires |

|STATE USE ONLY |

|DATE RECEIVED |DATE SENT |CONTROL SECTION |EMPLOYEE VERIFYING APPLICATION IDENTIFICATION |DATE |

|TYPE OF IDENTIFICATION: VALID PHOTO DRIVER LICENSE STATE-ISSUED PHOTO ID |

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|BIRTH CERTIFICATE VALID PASSPORT VALID MILITARY ID |

| |

|MILITARY DISCHARGE PAPERS OTHER (SPECIFY) |

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|Requests for National Driver Register (NDR) Record Checks |

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|Who May Request an NDR Record Check |

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|Each person wanting to request a copy of the NDR record on himself or herself (or to know whether such a record exists) should make a written request containing |

|the identifying information on the front side of this form. The information will be used only for identification verification and records search purposes. Forms |

|are available for both types of requests: those made for current or prospective employers and those individuals under the terms of the Privacy Act of 1974. |

| |

|Employer / Employee requests may be completed by either the current or prospective employer or by the current or prospective employee, but (1) the driver must sign|

|and authorize the request, and (2) the results of the NDR check will be mailed only to the current or prospective employer named. If no employer is named or the |

|form is changed, the request will not be processed. |

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|How to Request an NDR Record Check |

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|NDR record check requests must be notarized if mailed. Written requests presented in person shall also be accepted provided that the requesting party can prove his|

|/ her identity through the presentation of a document issued by a recognized organization (e.g., a driver license or a credit card) which contains a means of |

|verification such as a photograph or a signature. |

| |

|NDR results from Employer / Employee Requests will contain only the identification of the state(s) that have reported information on the driver to the NDR and only|

|information reported within the past 3 years from the date of the inquiry. Driver control actions initiated prior to that time, even if still in effect, will not |

|be included. Detailed information to confirm identity or to describe the contents of the driver record can be obtained only from the State(s). The name and address|

|of the driver licensing official will be provided for each state listed. |

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|NDR results from Individual-Privacy Act Requests will contain all information listed in the NDR records on the individual and will indicate any disclosures |

|previously made of the information and who received any reports provided. |

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|Requests for record information can be submitted, in writing to the following address: |

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|OHIO BUREAU OF MOTOR VEHICLES |

|ATTN: CDL SPECIAL CASE UNIT |

|P.O. BOX 16784 |

|COLUMBUS, OH 43216-6784 |

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